TheLancetMalaltiesPOstPART

Series
Maternal Health in the Perinatal Period and Beyond 3
Neglected medium-term and long-term consequences of
labour and childbirth: a systematic analysis of the burden,
recommended practices, and a way forward
Joshua P Vogel, Jenny Jung, Tina Lavin, Grace Simpson, Dvora Kluwgant, Edgardo Abalos, Virginia Diaz, Soo Downe, Veronique Filippi,
Ioannis Gallos, Hadiza Galadanci, Geetanjali Katageri, Caroline S E Homer, G Justus Hofmeyr, Tippawan Liabsuetrakul, Imran O Morhason-Bello,
Alfred Osoti, João Paulo Souza, Ranee Thakar, Shakila Thangaratinam, Olufemi T Oladapo
Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However,
the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth
complications that can emerge or persist months or years postnatally. This paper addresses these overlooked
conditions, arguing that their absence from the global health agenda and national action plans has led to the
misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the
6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term
complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their
prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology,
and inherent predispositions that contribute to these complications. We offer actionable recommendations to change
the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3.
This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.
Introduction
Accelerating the reduction of the maternal mortality ratio
(MMR) has been a singular focus of the maternal health
community for decades. This focus is reflected in more
than 30 years of international initiatives, strategies,
research prioriti­sation exercises, and quality improvement
activities,1–7 as well as being the primary goal of countless
regional, national, and local maternal health programmes
worldwide.8–10 Many such programmes have prioritised
intervention strategies to combat acute obstetric
emergencies, such as haemorrhage, hypertensive
disorders of pregnancy, and sepsis. Although these efforts
have collectively helped to drive the global MMR to its
lowest level in recorded history,11,12 many of the mediumterm and long-term (and often chronic) complications,
which emerge after 6 weeks following childbirth, are
comparatively less visible, or completely ignored.
Conditions such as depression, urinary and anal
incontinence, and sexual dysfunction can be caused or
exacerbated by pregnancy and childbirth but might only
present months, or even years, after childbirth. By this
time, women are no longer accessing postpartum care
services; historically, these services are only available up to
6 weeks after birth. These conditions can have lifelong
social, economic, and health consequences. The situation
can be worse in many low-income and middle-income
countries (LMICs), particularly those with a persistently
high burden of maternal mortality, than in high-income
countries (HICs). Even in countries where resources are
channelled to meet the global targets for the 2030
Sustainable Development Goals (SDGs) agenda, these
long-term conditions are often overlooked. And even in
settings where individuals present to health services with
birth-related complications after postpartum care has
ended, attending health providers might be ill-equipped
to address these chronic conditions. Midwifery and
obstetric training tends to focus on the management of
the leading, acute causes of maternal morbidity and
mortality.
One such complication—obstetric fistula—has bene­
fited from a dedicated stakeholder community, resulting
in high-profile advocacy, research, guidelines, and highquality improvement initiatives.13,14 Although more still
needs to be done to alleviate the suffering of women
affected by obstetric fistula, other fairly common
complications that affect women in the medium term and
long term after birth are rarely acknowledged or prioritised
in the global health landscape. A scarcity of data on these
conditions also impairs their visibility to key stakeholders.
Neglect in the maternal health agenda translates into low
visibility, financing, and collective effort to address these
conditions at global, regional, and national levels.
In this third paper in the Series on maternal health
in the perinatal period and beyond, we explore the
spectrum of medium-term and long-term compli­cations
that can arise from the processes of labour
and childbirth. We highlight the interplay between
human evolution, maternal physiology, and inherent
predisposition to these complications. We systematically
searched for epidemiological data on these conditions,
and systematically identified and summarised highquality clinical guidelines on their prevention,
identification, and treatment. We placed particular
emphasis on the implications for women living in LMICs.
www.thelancet.com/lancetgh Published online December 6, 2023 https://doi.org/10.1016/S2214-109X(23)00454-0
Lancet Glob Health 2023
Published Online
December 6, 2023
https://doi.org/10.1016/
S2214-109X(23)00454-0
See Online/Comment
https://doi.org/10.1016/
S2214-109X(23)00545-4 and
https://doi.org/10.1016/
S2214-109X(23)00553-3
This is the third in a Series of
four papers about maternal
health in the perinatal period
and beyond, to be published in
conjunction with eClinical
Medicine. All papers in the Series
are available at www.thelancet.
com/series/maternal-perinatalhealth
Maternal, Child and Adolescent
Health Program, Burnet
Institute, Melbourne, VIC,
Australia (Prof J P Vogel PhD,
J Jung MIPH, G Simpson MD,
D Kluwgant MD,
Prof C S E Homer PhD); UNDP–
UNFPA–UNICEF–WHO–World
Bank Special Programme of
Research, Development and
Research Training in Human
Reproduction (HRP),
Department of Sexual and
Reproductive Health and
Research, World Health
Organization, Geneva,
Switzerland (T Lavin PhD,
Prof I Gallos MD,
O T Oladapo MD); Centro de
Estudios de Estado y Sociedad
(CEDES), Buenos Aires,
Argentina (E Abalos MD);
Centro Rosarino de Estudios
Perinatales (CREP), Rosario,
Argentina (V Diaz MD); School
of Nursing and Midwifery,
University of Central
Lancashire, Preston, UK
(S Downe PhD); Department of
Infectious Disease
Epidemiology, London School
of Hygiene & Tropical Medicine,
London, UK (Prof V Filippi PhD);
Africa Center of Excellence for
1
Series
Key messages
• Many women experience labour-related and childbirth-related morbidity in the
medium-to-long term after childbirth (ie, beyond 6 weeks postnatally). Available data
show the most prevalent conditions are dyspareunia (35%), low back pain (32%),
urinary incontinence (8–31%), anxiety (9–24%), anal incontinence (19%), depression
(11–17%), tokophobia (6–15%), perineal pain (11%), and secondary infertility (11%).
• Other conditions that occur as a consequence of labour and childbirth are less
frequent (or less common), yet still have severe effects on women’s health and
wellbeing. These conditions include pelvic organ prolapse, post-traumatic stress
disorder, thyroid dysfunction, mastitis, HIV seroconversion, nerve injury, psychosis,
venous thromboembolism, and peripartum cardiomyopathy.
• Most prevalence data on these conditions come from high-income countries with well
resourced health systems. There are scarce population-level data from low-income
and middle-income countries, except for postpartum depression, anxiety, and
psychosis.
• Although high-quality guidelines do exist for some of these conditions, these are
mostly developed in, and tailored for, high-income country settings. Available
guidelines consistently highlight the importance of good-quality care at birth,
systematic clinical assessments, screening of postpartum women to identify those at
risk, and prompt management.
• To comprehensively address these conditions, broader and more comprehensive
health service opportunities are needed, which should extend beyond 6 weeks
postpartum and embrace multidisciplinary models of care. This approach can ensure
that these conditions are promptly identified and given the attention that they
deserve.
Population Health and Policy,
Bayero University, Kano,
Nigeria (Prof H Galadanci MSc);
S Nijalingappa Medical College
and HSK Hospital & Research
Centre, Bagalkot, India
(Prof G Katageri MS);
Department of Obstetrics and
Gynaecology, University of
Botswana, Gaborone,
Botswana
(Prof G J Hofmeyr DSc);
University of the
Witwatersrand and
Walter Sisulu University, East
London, South Africa
(Prof G J Hofmeyr); Department
of Epidemiology and
Department of Obstetrics and
Gynecology, Faculty of
Medicine, Prince of Songkla
University, Hat Yai, Thailand
(Prof T Liabsuetrakul PhD);
Department of Obstetrics and
Gynaecology, Faculty of Clinical
Sciences and Institute for
Advanced Medical Research
and Training, College of
Medicine, University of Ibadan,
Ibadan, Nigeria
(I O Morhason-Bello PhD);
Department of Obstetrics and
Gynaecology, University of
Nairobi, Nairobi, Kenya
(A Osoti PhD); Department of
Social Medicine, Ribeirao Preto
2
Neglected medium-term and long-term
complications arising from labour and childbirth
We conducted scoping literature searches and we
developed a list of priority health conditions (panel).
Eligible conditions were those affecting women that are
directly or primarily related to the effects of labour and
childbirth. This list includes conditions that are linked
to, or exacerbated by, intrapartum interventions. We
focused on those conditions emerging more than 6 weeks
postpartum (with no upper time limit). The term
neglected refers to those conditions that have been
overlooked or underappreciated in national and global
health agendas, as determined by consultation with the
authorship group.
These conditions can affect any person who has given
birth, regardless of parity or mode of birth. These
conditions can also emerge following use of intrapartum
interventions, such as caesarean section, instrumental
vaginal birth, episiotomy, hysterectomy, or laparotomy.
We excluded studies on conditions that occur primarily in
the short-term (within 6 weeks after birth), although we
acknowledge that some medium-term to long-term
conditions can develop within, but manifest beyond, this
period. We excluded conditions that arise directly from
comorbidities existing before pregnancy or that develop
during pregnancy, such as diabetes or pre-eclampsia. We
also excluded conditions affecting the child who has been
born of the pregnancy, as they were outside the scope of
this Series. In this paper, we refer to birthing parents as
women in keeping with our review search terms, but we
acknowledge that this group also includes gender-diverse
people, as well as adolescent girls.
Why do these complications occur?
The majority of the approximately 140 million women
who give birth globally every year do not have morbidity
in the 6 weeks after birth. However, many women, even if
they have an uncomplicated vaginal birth without the
need for interventions, will have a postpartum com­
plication. Substantial postpartum morbidity resulting
from a physiological process, such as labour and birth,
might seem counterintuitive. Figure 1 presents a
conceptual representation of the interplay between
predispositions that are intrinsic and extrinsic to
pregnancy, labour, and childbirth, and medium-term and
long-term maternal complications.
From an evolutionary standpoint, it is unsurprising
that profound maternal adaptations that favour newborn
survival have developed at the potential expense of longterm maternal health and wellbeing. In simplistic terms,
many evolutionary adaptations will favour the fetus that
carries genetic permutations to the next generation,
rather than the wellbeing of the mother. The human
brain consumes an extraordinary quantity of energy,
requiring a relatively higher blood flow than that of nonhuman brains.15 Human brain evolution has depended
upon development of an exceptionally efficient maternal–
fetal exchange interface, the placenta.16–18 Because brain
development, and consequently brain size, is privileged,
human infants are immature at birth compared with
other species, and are dependent on their family for years
of physical and cognitive development. Human brain
evolution has also resulted in a tight or disproportional
fetopelvic fit. This feature is reflected in the observation
that human births more frequently result in difficult
labours due to fetal head–pelvic disproportion, as
compared with other primates.19
The physiological changes of pregnancy affect multiple
maternal organ systems, including the cardiovascular
system (eg, spiral arteriole remodelling, reduced
peripheral resistance, increased cardiac output and blood
volume, and reduced blood pressure), immune system,
endocrine and hormonal changes (altering hormone
cycles and increased progesterone and oestrogen levels),
and ligament laxity.20–24 Although these changes occur
naturally during pregnancy (eg, relaxation of the pelvic
floor ligaments and musculature for easier passage of
the fetal head), they also increase the propensity for longterm complications to develop (eg, pelvic organ prolapse).
These risks can be compounded by social and clinical
factors (eg, poor social support, older or younger
maternal age, parity, obesity, or comorbidities), fetal
factors (eg, position or size), or whether intrapartum
complications occurred (eg, malpresentation, prolonged
second stage of labour, levator ani avulsion, or soft tissue
trauma). Effective and timely care around the time of
www.thelancet.com/lancetgh Published online December 6, 2023 https://doi.org/10.1016/S2214-109X(23)00454-0
Series
Panel: Medium-term and long-term conditions that can arise following labour and childbirth
Conditions related to labour and childbirth
Genitourinary conditions
• Fistula (any type)
• Pelvic floor disorders, including pelvic organ prolapse
(anterior or posterior vaginal wall prolapse); anal
incontinence; urinary incontinence
• Wound complications*
• Secondary infertility
Sexual health conditions
• Postpartum sexual dysfunction (including dyspareunia)
Mental health conditions
• Postpartum depression
• Anxiety disorders
• Birth-related post-traumatic stress disorder
• Postpartum psychosis
• Tokophobia
Cardiovascular conditions
• Peripartum cardiomyopathy
Neurological conditions
• Neuropathies
• Neural injury
Endocrine conditions
• Postpartum thyroiditis
Breast conditions
• Mastitis (including recurrent or chronic)
Metabolic conditions
• Postpartum weight retention
Infections
• HIV seroconversion
• Sepsis (excluding sepsis within 6 weeks postpartum)
Haematological conditions
• Chronic anaemia†
Effects on subsequent pregnancy
• Placenta praevia or accreta
• Placental abruption
• Uterine rupture
birth and a positive birth experience can thus prevent or
reduce the severity of medium-term and long-term
complications.
Although many labour and childbirth interventions are
offered to minimise harm for mother or baby, their
misuse or overuse can lead to iatrogenic complications.25
Episiotomy is a key example: routine episiotomy
remains prevalent, although randomised trials have long
shown that restrictive episiotomy policies, rather than
liberal or routine use, are associated with less posterior
perineal trauma and fewer complications.26 Similarly,
the injudicious use of uterotonics to augment weak
contractions during labour is a well known risk factor for
life-threatening complications, such as uterine rupture.
Conditions related to labour and childbirth interventions
(ie, iatrogenic conditions)
Conditions specific to caesarean section, laparotomy, hysterectomy,
or uterine rupture repair
• Surgical-site infection
• Pelvic adhesions
• Bowel obstruction
• Surgical injury
• Uterine rupture
• Wound, scar, or uterine complications
• Deep vein thrombosis
• Pneumonia
• Pain and nerve injury
• Menorrhagia and dysmenorrhoea (often as a result of
surgical intervention)
• Chronic pain
• Dyspareunia
• Secondary infertility
• Urinary incontinence; anal incontinence (often as a result of
or worsened by surgical intervention)
• Pelvic organ prolapse (often as a result of or worsened by
surgical intervention)
• Adverse psychological effects
• Adverse effects on subsequent pregnancies, including
placental defects
Medical School, University of
São Paulo, São Paulo, Brazil
(Prof J P Souza PhD); Croydon
University Hospital, London,
UK (R Thakar FRCOG); Institute
of Metabolism and Systems
Research, University of
Birmingham, Birmingham, UK
(Prof S Thangaratinam PhD)
Correspondence to:
Prof Joshua P Vogel, Maternal,
Child and Adolescent Health
Program, Burnet Institute,
Melbourne, VIC 3004, Australia
[email protected]
For more on obstetric fistula see
https://www.un.org/en/
observances/end-fistula-day and
https://endfistula.org/
Conditions related to episiotomy or perineal repair
• Perineal pain
• Urinary incontinence; anal incontinence
• Infections, injuries, or poorly healed perineum
• Dyspareunia
Conditions related to operative vaginal birth
• Pelvic organ prolapse
• Urinary incontinence; anal incontinence
*Secondary to perineal tears, episiotomy, or caesarean section (see subsequent items).
†Risk of chronic anaemia might be higher in women following postpartum haemorrhage,
anaemia during pregnancy, or other complications and conditions.
Women who survive uterine rupture can have devastating
consequences, such as secondary infertility due to
uterine wall repair and tubal ligation, partial or total
hysterectomy, or pelvic sepsis. Even when pharmaco­
logical (eg, oxytocin or misoprostol for labour induction),
mechanical (eg, instrumental vaginal birth), and surgical
(eg, episiotomy or caesarean section) interventions are
justified, they can still interfere with a woman’s recovery.
These complications can trigger adverse physical, social,
or psychological outcomes that can persist or emerge
long after childbirth.
The context of birth affects a woman’s natural response
to labour and childbirth. For example, birth in an
unfamiliar, unsupportive, or hostile clinical environment
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See Online for appendix
has been found to affect a woman’s emotional adjustment
to parenthood and is associated with adverse clinical
and emotional outcomes in the long term, such as a
woman’s sense of competence, confidence in adapting to
parenthood, and the initiation of breastfeeding.27,28 Sleep
deprivation, difficulty breastfeeding, low support in
parenting, and childcare-related challenges can also
increase the risk of postpartum depression.29 Broader
determinants of maternal health as presented in the first
paper30 in this Series—the physical environment and
climate, food security, housing, clean water, sanitation,
employment, and adverse family, social, or financial
circumstances, among others—can further accentuate
risks and worsen postpartum outcomes.31
Much of the long-term morbidity following childbirth
relates to mechanical injury. Vaginal birth involves
considerable stretching of soft tissues in the pelvic floor,
anal canal, and those supporting the bladder and
urethra.32 This stretching can result in levator ani muscle
injury—women with levator ani avulsion have greater
risks of symptomatic prolapse.33,34 Even in the absence of
overt perineal tears, ultrasound can reveal separation or
disruption of pelvic muscle fibres in some women.35
These clinical features can result in tissue laxity over
the longer term, leading to pelvic organ prolapse or
incontinence.36 Although this process can happen in
pregnant women with an uncomplicated vaginal birth,
studies have shown that forceps delivery, despite being
protective for the fetus, is associated with greater maternal
tissue damage.26 Softening of the symphysis pubis and
sacroiliac joints during pregnancy can also lead to longerterm symphyseal or pelvic girdle pain.37
As depicted in figure 1, an important concept
underpinning the interplay between the factors described
earlier and labour and childbirth-related complications is
time as an effect modifier. Both the intrinsic and extrinsic
factors that make women susceptible to developing these
complications tend to increase with labour duration. For
example, the likelihood of interventions during labour
increases as the first or second stages of labour become
atypically long. An understanding of this relationship
is fundamental to developing and taking preventive
measures to reduce the burden of chronic conditions
arising from the events surrounding labour and
childbirth.
The global burden of neglected medium-term
and long-term conditions after labour and
childbirth
Identifying data on the burden of these conditions
We systematically searched for the best available
estimates of the prevalence or incidence of adverse
conditions occurring in the long term after labour and
childbirth (appendix pp 2–4). Reliable global or national
estimates were our preferred data source; however, no
such estimates existed for any condition. We assessed
review quality using the AMSTAR tool (A MeaSurement
Tool to Assess systematic Reviews),38 a 16-point checklist
Environment
Social support
Birth
environment
Postpartum
care services
Physical and mental
health
Physiological
changes
Anatomical
changes
Social
changes
Birth
complications
Labour
and
birth
Pelvic organ
prolapse
Dyspareunia
PTSD
HIV seroconversion
Postpartum
depression
Short-term
complications
Postpartum
anxiety
Faecal
incontinence
Urinary
incontinence
Intrapartum
interventions
Postpartum
psychosis
Lower-extremity
nerve injury
Pregnancy
Childbirth
Placenta previa
or accreta
Tokophobia
Venous
thromboembolism
Cardiomyopathy
Postpartum
thyroiditis
Placental
abruption
Obstetric fistula
Mastitis
Preconception
Uterine
rupture
6-weeks
postpartum
Medium-term and long-term
(>6 weeks postpartum)
Secondary
infertility
Subsequent
pregnancies
Figure 1: Schematic of the medium-term and long-term conditions that arise from labour and childbirth
PTSD=post-traumatic stress disorder.
4
www.thelancet.com/lancetgh Published online December 6, 2023 https://doi.org/10.1016/S2214-109X(23)00454-0
Series
that categorises a review as high, medium, low, or
critically low quality, based on its methodology.
We identified 53 data sources—seven were repre­
sentative household surveys or large maternity registers
and 46 were systematic reviews. Two (4%) reviews were
high quality, six (13%) were moderate quality, 12 (26%)
were low quality, and 26 (57%) were critically low
quality. The table summarises the identified data
(appendix pp 29–37). For many conditions, differences
in estimated prevalence were probably affected by
different measurement tools, as well as whether
population-based or facility-based sampling was used.
Estimates from LMICs tended to rely on facility-based
sampling studies, which are more likely to produce
biased results. Although some conditions, such as
urinary incontinence, postpartum depression and
anxiety, and chronic pain had multiple data sources, we
were unable to identify any eligible data for several
conditions.
Adverse conditions affecting more than 10% of women
in the medium term or long term after birth
Conditions affecting more than 10% of women in the
medium-term or long-term postpartum period (beyond 6
weeks after birth) include dyspareunia (difficult or painful
sexual intercourse); anal or urinary incontinence, or both;
postpartum depression; tokophobia (severe fear of
childbirth); and chronic postpartum pain, such as low
back pain and perineal pain.
A high-quality review reported that 35% (95% CI
29–41) of postpartum women have dyspareunia, which
varied by time since birth: 43% of women had
dyspareunia from 2 months to 6 months postpartum,
22% from 6 months to 12 months, and 40% from
12 months to 24 months.53 Among women who gave
birth vaginally, the pooled prevalence of anal sphincter
defect on ultrasound was 26% (21–30), whereas
19% (14–25) of women had anal incontinence symptoms
at over 1 year after delivery.46 This study only assessed
women following vaginal delivery; we also searched for
other studies reporting prevalence on obstetric anal
sphincter injury after caesarean section or instrumental
vaginal delivery, but were unable to find reliable data. We
identified several moderate-quality reviews for
postpartum urinary incontinence from 6 weeks after
delivery, with prevalence estimates of 8%,45 12–19%,49
13·3%,50 and 31%.48 The National Health and Nutritional
Examination Survey (NHANES) of 6112 women in the
USA found that faecal incontinence (prevalence ranging
from 8% to 12%) and moderate-to-severe urinary
incontinence (ranging from 12% to 24%) increased with
parity.43 Factors including increasing age, some racial
and ethnic groups, low educational status, high BMI,
high number of comor­bidities, and hysterectomy were
associated with higher prevalence of incontinence.
Postpartum depression varied between HICs, which
have a prevalence of 11% (95% CI 9–13), and LMICs,
which have a prevalence of 17% (14–20).56 Three other
reviews (of low quality or critically low quality) compared
postpartum depression prevalence by country-income
category. All of these reviews reported a higher prevalence
of postpartum depression for women in LMICs (from
17·0% to 20·1%) compared with those in HICs (from
9·5% to 15·5%).56,58,60 Other reviews also found variation
in postpartum depression prevalence between countries,
and over time since birth.57–60 A high-quality review found
that the pooled prevalence of postpartum anxiety disorder
was 16% (95% CI 13·5–18·9), whereas 24·4% (16·2–33·7)
of women had self-reported anxiety symptoms.66 A
separate, moderate-quality review reported that the
pooled prevalence of postpartum anxiety disorder
seemed stable over time since birth, with 9·6% (3·4–15·9)
prevalence at 5–12 weeks postpartum, 9·9% (6·1–13·8) at
1–24 weeks, and 9·3% (5·5–13·1) beyond 24 weeks.67
Other than country income level, the latter two studies
did not identify any additional mediating factors.
A moderate-quality systematic review identified ten
studies from seven European countries reporting
that the prevalence of postpartum fear of childbirth
varied from 6·3% to 14·8%.68 A separate review found
tokophobia was present in 12% (95% CI 10–14) of women,
although there was substantial heterogeneity between
studies.69 Neither of these studies identified any
mediating factors or had timeframe limitations.
An analysis of 277 household surveys estimated
that the prevalence of secondary infertility—defined as
the inability to have a subsequent livebirth after a
previous birth—was 10·5% (9·5–11·7).52 We identified
two critically low-quality reviews on postpartum pain
conditions—one reported that the mean incidence of
first-onset low back pain from postpartum up to
menopausal age was 31·6% (range 19–53).74 The second
found the incidence of perineal pain among women with
an intact perineum following spontaneous vaginal birth
was 11% (95% CI 1–100) at 3 months postpartum,
although we note the wide confidence interval of this
finding.55
Adverse conditions affecting 1% to less than 10% of
women in the medium term or long term after birth
Conditions affecting 1% to less than 10% of women
include pelvic organ prolapse, birth-related postpartum
post-traumatic stress disorder (PTSD), postpartum
thyroid dysfunction, lactational mastitis, HIV sero­
conversion, and lower-extremity nerve injury. Three US
surveys reported that the weighted prevalence rates of
pelvic organ prolapse increased with parity, ranging from
1·4% to 4·5%.43 Two additional reviews estimated that
pelvic organ prolapse occurred in 6·0%44 and 13·7%45 of
women after vaginal birth, and 2·4%44 and 21·2%45 after
caesarean delivery. Increasing age, some racial and
ethnic groups, low education status, high BMI, various
comorbidities, and hysterectomy were associated with
increasing incidence of pelvic floor disorders.
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Evidence base*
Genitourinary conditions
Fistula (any type)
Household surveys in 19 sub-Saharan African countries suggest the lifetime prevalence of symptoms of vaginal fistula is 3·0 cases per 1000 women of reproductive
age (95% CI 1·36–5·5).39 Lifetime prevalence of fistula symptoms among women who ever had a livebirth ranged from 3·4% in Uganda to 5·8% in Malawi.40
A systematic review found that the incidence of obstetric fistula in LMICs ranged from 0 to 4·09 cases per 1000 births.41 A separate systematic review, which included
ten studies and 34 505 women, reported a pooled prevalence of obstetric fistula in LMICs of 0·29 per 1000 women (95% CI 0·00–1·07).42
Pelvic organ prolapse
Three US surveys conducted between 2005 and 2010 reported that the weighted prevalence of pelvic organ prolapse increased with parity, ranging from 1·4% to 4·5%.43
Two systematic reviews reported pelvic organ prolapse after vaginal birth occurred in 6%44 and 13·7%45 of women.
Anal incontinence
Three US surveys reported that the weighted prevalence of faecal incontinence increased with parity, ranging from 8·3% to 11·8%.43 A systematic review (25 studies
including 2523 women) found that, among women who gave birth vaginally, the pooled prevalence of anal sphincter defect on ultrasound was 26% (95% CI 21–30)
and of anal incontinence symptoms was 19% (14–25).46 A separate systematic review reported that faecal incontinence47 affected 27% of women at 6 weeks to 1 year
postpartum, 33% of women between 2 years and 5 years postpartum, and 26% of women at over 5 years postpartum.
Urinary incontinence
Three US surveys reported that the weighted prevalence of moderate-to-severe urinary incontinence increased with parity, ranging from 11·8% to 23·9%
(6112 women).43 A systematic review reported that the mean (weighted) prevalence of urinary incontinence in postpartum women between 6 weeks and 12 months
in HICs was 31% (95% CI 26–36; 24 studies, 24 064 women), and the prevalence ranged between 10% and 63%.48 Other systematic reviews estimated the prevalence
of stress urinary incontinence at 7·9%,45 12–19%,49 13·3%,50 and 15%.44 One systematic review reported a prevalence of stress urinary incontinence in women with
levator ani muscle avulsion of 29–69%, at least 1 year after childbirth.51
Sexual and reproductive health conditions
Secondary infertility
An analysis of 277 household surveys estimated that the prevalence of secondary infertility was 10·5% (95% CI 9·5–11·7).52
Postpartum sexual
dysfunction (including
dyspareunia)
A systematic review reported that the overall prevalence of dyspareunia was 35% (95% CI 29–41).53 In total, 43% of individuals had dyspareunia from 2 to 6 months
postpartum (36–50), 22% (15–29) from 6 to 12 months postpartum, and 40% (33–47) from 12 to 24 months postpartum (one study). This review also reported that
89% (83–93) of women had resumed sexual intercourse within 2 to 6 months postpartum and 99% (97–100) within 6 to 12 months.53 A separate systematic review
reported that 82–90% of women resumed sexual intercourse between 6 months and 9 months postpartum, and at least one problem was reported in 36–43% of women
at 6 months and 80–91% of women at 12 months.54 Another review reported that the pooled prevalence of dyspareunia for women with an intact perineum following
spontaneous vaginal birth was 15% (5–44) at 6 months postpartum and 16% (8–32) at 12 months postpartum.55
Mental health conditions
Postpartum depression
A systematic review reported a pooled prevalence of postpartum depression of 14% (95% CI 12–15).56 These authors also reported a postpartum depression prevalence
of 12·9% at 8 weeks postpartum, 17·4% (5·9–28·9) at 12 weeks postpartum, and 13·6% (10·4–16·8) at 24 weeks postpartum. Prevalence varied by country economic
level, with 17·0% (14–20) in developing countries and 11·0% (8·8–13·2) in developed countries (according to terminology of the study). Four other systematic reviews
reported on pooled prevalence of postpartum depression and reported findings of: 18·7% (17·8–19·7) in LMICs and 9·5% (8·9–10·1) in HICs;57 17·7% (16·6–18·8)
between 4 weeks and 52 weeks postpartum, ranging from 3·1% to 37·7%;58 16% (13–19) at 4–6 months, 20% (11–29) at 7–12 months, and 25% (12–39) at over
12 months postpartum in women without a previous history of depression;59 and 15·9% (14–18) at 3–6 months, 17·9% (13–24) at 6–12 months, and 17·9% (14–23) at
over 12 months postpartum.60
PTSD
A systematic review reported the pooled prevalence of PTSD was 1·1% (95% CI 0·5–2·0).61 A separate systematic review reported a pooled prevalence of PTSD of
1·4% (0·3–6·5) at 3 months and 6·8% (1·6–24·5) at 6 months postpartum.62 A third systematic review reported the rate of postpartum PTSD at 3 to less than
6 months postpartum was between 3·4% and 6·7%.63
Postpartum psychosis
A systematic review identified one study that reported prevalence of postpartum psychosis in the USA of 5 in 1000 women.64 A separate systematic review (five
studies in LMICs) reported a cumulative incidence of postpartum psychosis of 1·1 per 1000 births, and the prevalence between studies ranged from 1·1 to 16·7 per
1000 births.65
Anxiety disorders
A systematic review reported that the pooled prevalence of postpartum anxiety disorder was 16% (95% CI 13·5–18·9) and of self-reported anxiety symptoms was
24·4% (16·2–33·7).66 A separate systematic review reported the pooled prevalence of postpartum anxiety disorder was 9·6% (3·4–15·9) at 5–12 weeks postpartum,
9·9% (6·1–13·8) at 1–24 weeks postpartum, and 9·3% (5·5–13·1) at over 24 weeks postpartum.67 A third systematic review reported the pooled prevalence of
postpartum generalised anxiety disorder was 2·6% (1·3–3·8).61
Secondary tokophobia
A systematic review reported prevalence rates of fear of childbirth varied from 6·3% to 14·8% (as defined by a Wijma delivery expectancy/experience questionnaire
score ≥85) in ten studies across seven European countries.68 A separate systematic review (including 17 studies) reported the pooled prevalence of tokophobia was
14% (95%CI 12–16) overall, and 12% (10–14) among multiparous women.69
Cardiovascular conditions
Peripartum
cardiomyopathy
An analysis of the National Inpatient Sample database in the USA reported the prevalence of peripartum cardiomyopathy as 33·5 per 100 000 livebirths in women
aged 15–35 years, and 77·6 per 100 000 livebirths in women aged 36–54 years.70 A systematic review reported that the incidence of peripartum cardiomyopathy varied
between countries, with the highest rates in Nigeria (1 in 102 births) and lowest in Japan (1 in 15 533 births).71
Venous
thromboembolism
A systematic review reported the pooled incidence rate of venous thromboembolism during pregnancy and puerperium was 1·4 per 1000 (1·0–1·8 per 1000), and the
authors estimated that 57·5% (95% CI 20·9–63·9) of these venous thromboembolism events occur postpartum (rather than antepartum).72
Neurological conditions
Neuropathies and
neural injury
A systematic review reported that the incidence of lower extremity nerve injury up to 6 months postpartum ranged from 0·3% to 2·3%.73
Chronic pain
A systematic review reported the incidence of first-onset low back pain ranged from 19% to 53%, with a mean incidence of 31·6%.74 A separate systematic review reported
an incidence of perineal pain of 11% for women with an intact perineum following spontaneous vaginal birth at 3 months postpartum (95% CI 0·01–100).55
(Table continues on next page)
A systematic review reported a 1·1% (95% CI 0·5–2·0)
prevalence of postpartum PTSD,61 whereas another review
found prevalences of 1·4% (0·3–6·5) at 3 months and
6·8% (1·6–24·5) at 6 months.62 A third review reported
6
that postpartum PTSD at 3 to less than 6 months
postpartum was between 3·4% and 6·7%.63 Studies
reported that comorbidities, such as depression, history of
psychological problems or trauma, emergency caesarean
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Evidence base*
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Endocrine conditions
Postpartum thyroiditis
A systematic review reported the pooled prevalence of postpartum thyroid dysfunction was 8·1% (95% CI 7·8–8·2) and ranged from 0·9% to 11·7%. The authors also
reported a prevalence of 7·9% (7·7–8·1) at up to 6 months postpartum, 6·4% (6·3–6·5) at up to 9 months postpartum, and 9·2% (9·1–9·3) at up to 12 months
postpartum.75
Breast conditions
Mastitis
A systematic review reported the pooled incidence rate of lactational mastitis at 0–25 weeks postpartum was 11·1 episodes per 1000 breastfeeding weeks (95% CI
10·2–12·0). Prevalence ranged from 2·5% to 20%.76
Infections
HIV seroconversion
A systematic review reported the pooled HIV incidence rate was 2·9 per 100 person-years postpartum (95% CI 1·8–4·0).77
Effects on subsequent pregnancy
Placenta previa or
accrete
A systematic review reported the increased absolute risk of placenta accreta following caesarean section.78 The absolute risk was: 3·3 per 10 000 for no caesarean section;
12·9 per 10 000 after one caesarean section; 41·3 per 10 000 after two caesarean sections; 78·3 per 10 000 after three caesarean sections; 217 per 10 000 for four caesarean
sections; and 230 per 10 000 for five or more caesarean sections.
Placental abruption
A systematic review reported the incidence of abruption ranged from 0·01% to 5·1%.79
Uterine rupture
An analysis of INOSS data (nine European countries) reported the prevalence of complete uterine rupture was 3·3 per 10 000 births (95% CI 3·1–3·5). Prevalence varied
widely between countries, from 1·6 to 7·8 per 10 000 births.80
Conditions specific to caesarean section, laparotomy, or hysterectomy
Uterine and wound
complications
A systematic review reported the pooled incidence of chronic wound pain after caesarean section was 15·4% (95% CI 9·9–20·9) at 3–6 months postpartum;
11·5% (8·1–15·0) at 6–11 months postpartum; and 11·2% (7·4–15·0) at 12 months or more postpartum.81
Uterine rupture
An analysis of INOSS data (nine European countries) reported the overall prevalence of complete uterine rupture after caesarean section was: 22 per 10 000 births
(95% CI 21–24) in women with previous caesarean section, and 35 per 10 000 births (32–37) in women with previous caesarean section and labour.80 Prevalence varied
widely between countries, ranging from 8 to 68 per 10 000 births in women with previous caesarean section, and from 16 to 80 per 10 000 births in women with
previous caesarean section and labour. A WHO multicountry survey analysis reported the incidence of uterine rupture in women who have had a caesarean section was
45 per 10 000 births, ranging from 0·1% to 2·5%.80 A systematic review reported the absolute risk of uterine rupture in vaginal birth after caesarean section was
0·87% and after planned repeat caesarean section was 0·09%. Uterine rupture rates ranged from 0% to 1·69%.82
Scar complications
A systematic review reported the prevalence of caesarean section scar defect ranged between 24% and 88% on ultrasonography.83 A separate systematic review
reported the prevalence of a niche (caesarean section scar defect) in women with a history of caesarean section varied between 56–84% using contrast-enhanced
sonohysterography and 24–70% using transvaginal sonography.84
Venous
thromboembolism
A systematic review reported the pooled incidence of venous thromboembolism following caesarean section was 2·6 per 1000 caesarean section births (95% CI
1·7–3·5).85 In studies with a longer and better postpartum follow-up, incidence increased to 4·3 per 1000 caesarean section births (1·0–4·3).
Pain, nerve injury,
chronic pain
A systematic review reported the incidence of chronic pain following a caesarean section at 2 to 6 months postpartum ranged between 4% and 41·8% (17 studies).86
A separate systematic review reported the pooled incidence of chronic postsurgical pain 3 to 6 months following a caesarean section was 15·4% (95% CI 9·9–20·9).81
A third systematic review reported the pooled prevalence of chronic pain following a caesarean section was: 19% (12–23) at 2 to 5 months, 13% (9–17) at 6 to
11 months, and 8% (6–10) at 12 months or more.87 A fourth systematic review reported pelvic pain after caesarean section occurred in 1·3% of women.44
Secondary infertility
A systematic review reported secondary infertility among women with caesarean section delivery was 43%.44
Pelvic organ prolapse
Analysis of three USA surveys reported the weighted prevalence of pelvic organ prolapse among women who had caesarean delivery only was 1·9% (95% CI 1·1–3·3).
The weighted prevalence among women with previous hysterectomy was 5·4% (4·0–7·3).43 A systematic review reported that pelvic organ prolapse after caesarean
section occurred in 21·2% of women, and stress urinary incontinence in 10·2% of women.45 A separate systematic review reported pelvic organ prolapse after
caesarean section was 2·3%.44
Urinary incontinence
Analysis of three USA surveys reported the weighted prevalence of urinary incontinence among women who had caesarean section was 12·7% (95% CI 10·4–15·4).
The weighted prevalence among women with previous hysterectomy was 29·5% (26·8–32·3).43 A systematic review reported the absolute prevalence of stress urinary
incontinence among women who had had one or more caesarean sections ranged from 5% to 15%.49 A separate systematic review reported that urinary incontinence
after caesarean section occurred in 14% of women.44 All studies reported caesarean delivery had lower rates of urinary incontinence compared with vaginal delivery.43,44,49
Anal incontinence
Analysis of three USA surveys reported the weighted prevalence of faecal incontinence among women who had a caesarean section was 6·4% (95% CI 4·6–8·8).
The weighted prevalence among 1717 women with previous hysterectomy was 16·6% (14·6–18·8).43 A systematic review reported the rate of faecal incontinence after
caesarean section was 3·6%.44 One study reported caesarean delivery had lower rate of anal incontinence than vaginal birth,43 but one study reported no statistically
significant difference in rates.44
PTSD
A systematic review reported the pooled prevalence of PTSD after caesarean section was 9·0% (95% CI 4·6–15·6) at more than 8 weeks postpartum, and 4·8% at
4 weeks to more than 12 months postpartum (2·0–9·7).88
Adverse effect on
A systematic review reported that the absolute risk of previa associated with caesarean section was 12 per 1000 deliveries (95% CI 8–15). The overall incidence of
subsequent pregnancies abruption with any previous caesarean section was 1·2–1·5%, and the rate of abruption was 10·3–15·0 per 1000 deliveries. The reported incidence of placenta accreta
ranged from 11% in women with one previous caesarean section to 67% in women with 5 or more previous caesarean section deliveries.89 A separate systematic
review reported the increased absolute risk of placenta accreta following caesarean section was 3·3 per 10 000 for no caesarean section, 12·9 per 10 000 after one
caesarean section, 41·3 per 10 000 after two caesarean sections, 78·3 per 10 000 after three caesarean sections, 217 per 10 000 for four caesarean sections, and 230 per
10 000 for five or more caesarean sections.78
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section, pregnancy complications, and low levels of social
support were risk factors for postpartum PTSD.62,63 The
pooled prevalence of postpartum thyroid dysfunction was
8·1% (7·8–8·2), although this varied from 7·9% (7·7–8·1)
at up to 6 months postpartum, 6·4% (6·3–6·5) at up to
9 months, and 9·2% (9·1–9·3) at up to 12 months; no data
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Evidence base*
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Conditions related to episiotomy or perineal repair
Incontinence
A systematic review reported the prevalence of urinary incontinence ranged from 0·7% to 29·1%, and anal incontinence ranged from 2·8% to 29·1% among women
with episiotomy.90 A separate systematic review reported the prevalence of urinary incontinence ranged from 0% to 75·2%.91
Postpartum sexual
dysfunction
A systematic review reported the prevalence of sexual dysfunction ranged from 7·9% to 64·9%.90 A separate systematic review reported the incidence of
dyspareunia for women with a repaired second-degree tear or episiotomy following spontaneous vaginal birth was 16% (95% CI 2–100) at 6–7 weeks postpartum,
and 19% (13–28) at 3 months postpartum.
For several conditions, no systematic reviews of prevalence were identified: cervical incompetence, wound complications, Grave’s disease, Sheehan’s syndrome, postpartum weight retention, abnormal
placentation, chronic anaemia, some post-procedural complications (surgical site infection, pelvic adhesions, bowel obstruction, surgical injury, pneumonia, menorrhagia, dysmenorrhea, sexual dysfunction),
some post-episiotomy complications (poorly healing perineum or perineal pain after episiotomy), and conditions related to operative vaginal birth. HIC=high-income country. INOSS=The International Network
of Obstetric Survey Systems. LMIC=low-income and middle-income country. PTSD=post-traumatic stress disorder. *When confidence intervals were available in the support evidence base, they were reported;
however, several reviews did not provide confidence intervals.
Table: Summary of epidemiological data on medium-term and long-term conditions after labour and childbirth
were presented after 12 months postpartum and no
mediating factors were identified.75 We identified one,
critically low-quality review that reported on lactational
mastitis.76 This review reported that at 0–25 weeks
postpartum, 11·1 (95% CI 10·2–12·0) episodes of mastitis
occurred per 1000 breastfeeding weeks, and prevalence
from 0–12 months postpartum ranged from 2·5% to
20% across studies.76 Nipple damage or nipple pain, and
infection with Staphylococcus aureus were reported risk
factors for mastitis. Similarly, a critically low-quality
review on HIV seroconversion found that the pooled HIV
incidence rate was 2·9 (1·8–4·0) per 100 person-years
postpartum.77 Studies identified pregnancy-induced
physiological changes, sexually transmitted infections and
other genital tract infections, vitamin A deficiency, severe
anaemia, and younger age (<20 years) as potential risk
factors for HIV incidence. The incidence of lower
extremity nerve injury up to 6 months postpartum ranges
from 0·3% to 2·3%, and occurred more often in women’s
first births and when neuraxial (epidural) analgesia or
anaesthesia was used.73
Adverse conditions affecting less than 1% of women in
the medium term or long term after birth
Conditions affecting less than 1% of women include
postpartum psychosis, venous thromboembolism,
peripartum cardiomyopathy, and obstetric fistula. A
moderate-quality review reported that the cumulative
incidence of postpartum psychosis up to 1 year
postpartum ranged from 1·1 to 16·7 per 1000 births, and
did not report any mediating factors.65 A low-quality
review found the pooled incidence rate of venous
thromboembolism during pregnancy and puerperium
was 1·4 per 1000 women (95% CI 1·0–1·8), of which
57·5% (20·9–63·9) occurred postpartum; no specific
timeframe or mediating factors influencing incidence
were reported in this review.72
An analysis of the National Inpatient Sample database
in the USA reported that the prevalence of peripartum
cardiomyopathy was 33·5 per 100 000 livebirths in
women aged 15–35 years, and 77·6 per 100 000 livebirths
8
in women aged 36–54 years.70 The incidence differed
between racial and ethnic groups, with highest incidence
in Black groups, followed by White and Hispanic groups.
A systematic review found that the incidence of
peripartum cardiomyopathy varied between countries,
with the highest rates in Nigeria (1 in 102 births) and the
lowest in Japan (1 in 15 533 births).71,77
There were conflicting estimates on obstetric fistula
prevalence. A meta-analysis of household surveys from
19 sub-Saharan African countries suggested that the
lifetime prevalence of symptoms of vaginal fistula was
3·0 cases per 1000 women of reproductive age (95% CI
1·4–5·5).39 A separate analysis of three household surveys
on obstetric fistula symptoms among women who have
had a livebirth found considerably higher rates than the
previous meta-analysis, ranging from 3·4% in Uganda to
5·8% in Malawi.41 Other systematic reviews, focused on
women in LMICs, reported obstetric fistula prevalence
ranging from 0 to 4·09 cases per 1000 births,41 to 0·29
cases per 1000 women (0·00–1·07).42 None of these
studies identified mediating factors influencing
incidence of obstetric fistula, other than country.
Clinical guidelines for the prevention,
recognition, and treatment of medium-term
and long-term morbidities arising from labour
and childbirth
Guidelines support clinicians on what interventions
they should (or should not) offer and are ideally informed
by a systematic assessment of available evidence.92 We
conducted a systematic search to identify high-quality
guidelines on the prevention, screening, diagnosis, and
treatment of the adverse conditions of interest, from
2010 onwards (appendix pp 18–20). Because guidelines
use different terminology, we extracted and classified all
recommendations on the basis of their directions,
regardless of the grading recommendations and levels
(hierarchy) of evidence or recommendation strength. We
did not critically appraise the evidence base for individual
recommendations. We identified 157 guidelines, of
which 46 were high-quality (appendix pp 41–42).93
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46 high-quality guidelines were published between
March, 2012, and March 30, 2022 by 72 different
organisations (appendix pp 41–42). They pertained to
19 of the conditions that we selected, with most issued
from HICs (the UK, the USA, European countries,
Canada, and Australia). None were developed by an
LMIC-based organisation. However, seven were WHO
guidelines recommended for use internationally,
which were developed with the involvement experts of
various disciplines and from a range of countries
(including LMICs). These guidelines covered postpartum
depression (n=10), urinary incontinence (n=9), uterine
and wound complications (n=8), and postpartum anxiety
(n=7). There were few high-quality guidelines for other
conditions, such as fistula, mastitis, and postpartum
thyroiditis. No high-quality guidelines were identified
for several conditions, such as secondary infertility and
neuropathies. We extracted 898 recommendations from
these 46 guidelines, which were categorised based on
type (appendix pp 50–71).
A key theme across the guidelines was the need for
providers to consider a broad range of functional,
emotional, behavioural, sexual, and other quality-of-life
issues affecting women in the postpartum period. Several
guidelines recommended systematic clinical assessments
or formal screening using validated tools to identify
those who have or are at risk of adverse conditions. We
synthesised recommendations relating to clinical
assessment and screening into a simplified list to help
providers detect or exclude these conditions (figure 2).
These practices are relevant to providers working in
postpartum care, as well as those working in other
health-care services in which they encounter women
beyond the standard 6-week postpartum period.
Opportunities to identify these conditions as early as
possible should not be missed, so treatment can be
commenced promptly. An overarching message is that
timely, women-centred, and evidence-based care is the
most effective preventive (or reparative) strategy for
many complications.
How can we improve the prevention,
recognition, and treatment of medium-term
and long-term conditions arising from labour
and childbirth?
There is a scarcity of comprehensive evidence regarding
the prevalence of these conditions. Many reviews had
methodological gaps, which resulted in low or critically
low-quality assessments using the AGREE-II tool.
Authors of included reviews noted the challenges in
pooling prevalence data from studies that used different
clinical definitions, diagnostic tools, and sampling
History and clinical assessment
Mental health
• How is her emotional, physical, and general wellbeing?
• History of any physical or mental health issues?
• Healing of any wounds, and whether signs or
symptoms of wound infection are present?
• Presence of non-specific symptoms (eg, headache,
fatigue)?
• Any back pain or nipple and breast discomfort?
• Consider screening for peripartum cardiovascular
diseases (ideally using an algorithm).
• Offer HIV testing for women who missed testing during
pregnancy (where appropriate).
• Are depressive symptoms present?
• Screen for depression or anxiety using a validated tool.
• Are there risk factors for perinatal mental health
conditions, or previous contact with mental health
services?
• What are her coping strategies for dealing with
day-to-day matters?
• Is interpersonal violence or abuse present?
Understand
Genitourinary system
• What is her attitude towards and experience of
pregnancy and childbirth?
• Any problems experienced by her or the baby?
How is the mother–baby relationship?
• What are her social networks, quality of interpersonal
relationships, and living conditions like?
• Is social isolation a factor?
• What are her housing, employment, and economic
arrangements?
• Is immigration status an issue?
• What are her carer responsibilities (other children,
young people, or adults)?
• Are there any predisposing and precipitating factors
for pelvic floor disorders?
• Assess bowel and urinary function; is faecal or urinary
incontinence present?
• Assess for uterine tenderness, lochia, or symptoms of
inflammation.
• Assess for pelvic floor dysfunction.
• Is there vaginal discharge or bleeding?
• Does she have perineal pain? What is her perineal
hygiene like?
• Assess for perineal or anal sphincter injury, examine
perineal or vaginal tears and healing of any perineal
wound.
• Ask about resumption of sexual intercourse and
whether dyspareunia is present.
Figure 2: Recommended practices and actions for health providers, in order to identify postpartum women who are at risk of developing or currently have a
medium-term or long-term condition
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strategies, leading to greater uncertainty in pooled
estimates. Although we sought prevalence estimates
specific to LMICs, few reviews had sufficient data in this
regard; thus, the burden of medium-term and long-term
conditions in LMICs remains largely unknown. Even
where LMIC-based data were available, there is an overreliance on facility-based studies with non-representative
sampling. These knowledge gaps highlight the need for
robust, high-quality, population-based prevalence studies
in LMICs to guide prioritisation and decision-making.
Although we found high-quality clinical guidelines for
many conditions, a major concern was the paucity of
guidelines developed within, or for, LMIC contexts
specifically. Although the paucity of guidelines does not
reflect the health-care provider’s awareness of these
conditions and their clinical practice, it is nonetheless
concerning. We hypothesise that in many countries these
long-term complications are underappreciated, underrecognised, and under-reported. Developing high-quality,
evidence-based guidelines requires substantial resources
and methodological expertise. Efforts to adapt existing
guidelines to low-resource settings, using tools such as
ADAPTE, can be useful.94 However, guidelines alone are
insufficient to improve clinical practice and women’s
health outcomes—they need to be accompanied by
proactive knowledge transfer strategies.92
One key theme from the guideline review was that
women in the postpartum period might face a range of
psychological, emotional, and physical challenges.
These challenges can widely affect a woman’s health
and wellbeing, and that of her family. Supporting
women in navigating these challenges requires a
flexible and responsive postpartum care model—one
that is person-centred and respectful, but also
multidisciplinary, with integration of diverse health
services. A model like this would ensure that women
who have or are at risk of adverse conditions are
identified as early as possible. Effective prevention of
medium-term and long-term complications demands
the provision of high-quality, timely, and evidencebased care during pregnancy, childbirth, and the early
postpartum period. This care should allow the risky
extremes of the so-called too much, too soon and too
little, too late situations to be avoided.25
Formal postpartum care services have historically
focused on the 6-week period after birth, reflecting the
official WHO definition of the postpartum period of up
to 42 days post-birth.95 However, this timeframe is not fit
for purpose. The heightened risks from childbirth do
not end at this somewhat arbitrary timepoint—they can
persist up to and beyond 1 year after birth. Gazeley and
colleagues found that in 12 sub-Saharan African
countries, the risk of mortality in postpartum women
was still 20% higher at 42 days to 4 months postpartum,
as compared with the baseline risk of 12–17 months
postpartum.96 Kassebaum and colleagues estimated that
35·6% of maternal deaths occurred between 24 h and
10
42 days postpartum, yet a further 12·1% occurred
between 43 days and 1 year postpartum.97 A multitude of
childbirth-related conditions, many of considerable
prevalence, will first present after 42 days postpartum.
Women who have antenatal complications, such as
gestational diabetes or pre-eclampsia, are at an increased
risk of non-communicable diseases in later life, such as
diabetes and cardiovascular disease, and thus require
additional preventive care into later life. Acknowledging
that the coverage of postnatal care in many countries is
poor,98 current postnatal care models are not adequately
oriented to the timing and diversity of postpartumrelated challenges that women face.99 Given the diverse
nature of the conditions that we have identified, there is
a need for more and better integration of postnatal care
services with other disciplines to ensure that women
have access to primary care providers, mental health
services, or other relevant specialties, as required.
Research priorities for medium-term and longterm conditions after labour and childbirth
A literature search identified ten research prioritisation
activities for only a few of the adverse conditions we
considered. These conditions included obstetric
fistula,100,101 faecal incontinence,102,103 urinary incon­
tinence,104 maternal mental health,105 peripartum cardio­
myopathy,106 HIV in women in the postpartum period,107
and postpartum infections;108,109 and a WHO-led
prioritisation that captured a few other long-term
conditions.5 This inconsistent approach reflects the
absence of a comprehensive research agenda that
addresses the full range of medium-term and long-term
consequences after childbirth.
A key finding from our review is that more and better
measurement of these conditions is urgently required.
Although data suggest that some conditions might be
more prevalent in LMICs, the scale of the burden in these
countries is not fully known. Representative prevalence
data need to be gathered and reported in a standardised
way to be useful to clinicians, stakeholders, and policy
makers. Converging on standardised measurement tools
and study designs that ensure prevalence data are reliable,
comparable, and representative is necessary.110 Epidemio­
logical research to understand drivers, risk factors,
and rates of medium-term and long-term complications;
why rates differ across settings; and the effects of these
complications on women’s quality of life and wellbeing are
also needed. An overarching methodological consideration
is the need for population-based, rather than facility-based,
sampling. Facility-based samples are typically composed of
women who have access to care or have elected to seek it,
and as such are not representative of all women in the
postpartum period. This problem is more pronounced
in settings where women’s access to health services is
poor. Conditions such as anal incontinence, urinary
incontinence, postpartum depression and anxiety,
and sexual dysfunction can be difficult for women and
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health-care providers to talk about; careful consideration is
required to determine how these conditions can be
accurately ascertained and reported.
Interventional research is needed on how we can most
effectively prevent or reduce the effects of these
conditions, particularly in LMIC settings. Imple­
mentation research is also required to understand
how effective practices can be operationalised, and at
what cost. Many of the guidelines that we identified
recommend multidisciplinary models of care, special
investigations, and interventions that require substantial
health resources. Development and testing of novel,
responsive, and person-centred models of postnatal care
that can work for women in resource-limited settings is
long overdue. Although the consideration of economic
evidence was outside the scope of our analysis, it is
probable that these conditions impose a considerable
(and often avoidable) cost burden on health systems and
societies. Economic evaluations are therefore crucial to
attract attention and generate meaningful policy change
around these conditions.
A call to action
In conclusion, we call for greater recognition, improved
measurements, and collective action and funding to
prevent and manage medium-term and long-term
consequences of labour and childbirth, many of which
affect millions of women worldwide. These conditions
are not mainstream in the global agenda or national
health action plans of many countries, meaning that they
are not prioritised from a public health perspective. This
neglect has led to an unfounded misperception that these
conditions are uncommon or unimportant. However, the
trajectory of a woman’s long-term health, wellbeing, and
quality of life is shaped by her experiences during labour
and childbirth, and the quality of care she received at that
time. Efforts to reach universal health coverage need
to address how these medium-term and long-term
conditions after childbirth can be better prevented,
identified, and treated. Widespread awareness-raising is
required, and lessons need to be learned from advocacy
success stories, such as the International Day to End
Obstetric Fistula. The success of fistula-related advocacy
includes framing fistula as a health and human rights
issue,111 SDG target-setting,112 generating prevalence data
and global estimates,39,42 implementing national policy
initiatives113 and norms and standards from international
agencies,13,114,115 and multilateral advocacy at local, national,
regional, and global levels.15
Several measures can be taken immediately to improve
this situation. First, policy makers, clinicians, and those
who manage health services can revisit their current care
arrangements. They can ask questions such as: which
part of the health service is responsible for the prevention
and management of childbirth-related conditions, and
how can the needs of women in the postpartum period
be better met? How can postpartum care be extended or
Search strategy and selection criteria
To identify epidemiological data or estimates on prevalence, we did a comprehensive search
of UN agency websites, population-representative household survey datasets, national and
international maternity registry datasets, as well as PubMed, Embase, CINAHL, and
Epistemonikos for systematic reviews. The search was conducted from Jan 1, 2000, to
April 12, 2022. We searched for studies with several variations of the primary key search
terms “pregnancy” or “childbirth” or “postnatal”, and “prevalence”, and terms related to the
conditions of interest. We used a hierarchical search strategy to identify the best available
estimate or evidence of the burden (ie, prevalence or incidence), with a specific focus on
data for low-income and middle-income countries (appendix pp 2–4). The titles and
abstracts of search results were independently screened and selected against prespecified
eligibility criteria. When multiple systematic reviews were available, we prioritised by
recency, their eligibility criteria and limitations, and population representativeness
(appendix pp 2–4). For guidelines, we adopted the Institute of Medicine’s definition of a
guideline as “statements that include recommendations, intended to optimize patient care,
that are informed by a systematic review of evidence and an assessment of the benefits and
harms of alternative care options”. We first developed a list of 54 organisations producing
guidelines that are used internationally for the conditions of interest and searched their
websites directly for guidelines published since 2010. We also did a systematic search of
MEDLINE, Trip database (Guideline filter function), and the Guideline International Network
website (inception to May 10, 2022). Recovered citations were screened in duplicate.
We used the AGREE-II instrument to identify high-quality guidelines. AGREE-II uses 23
criteria to assess the quality of a clinical practice guideline, on the basis of the guideline’s
scope, purpose, stakeholder involvement, rigour of development, clarity of presentation,
applicability, and editorial independence. From the 46 high-quality guidelines, individual
recommendations were extracted and analysed (appendix pp 50–71).
optimised to identify these conditions, and to better link
with different disciplines and community-based services?
How can the health system response and care availability
for these conditions be strengthened? Second, it is
important to amplify the voices of women, representative
organisations, patient advocacy, and other communityled groups that are drawing attention to these conditions,
often without the support of other maternity or women’s
health stakeholders. Third, greater investment is needed
in epidemiological, interventional, and implementation
research, as well as evidence-based guidelines for these
conditions, to drive positive change. This research should
engage with, and be driven by, key stakeholders in
affected communities. Fourth, women and families
should have access to evidence-based information on
prevalence, prevention, and management of mediumterm and long-term complications of childbirth. Fifth,
postpartum period definitions as a threshold for postnatal
care services should be reconsidered, as should the
period beyond 42 days. Last, but not least, countries
should prioritise the development and implementation
of health policies that address the full range of health
conditions that tend to emerge long after the time of
birth, but which are traceable to labour and childbirth
processes and events.
Contributors
JPV, IG, JPS, ST, and OTO were members of the steering committee that
conceptualised and drafted the outlines for the papers in this Series.
www.thelancet.com/lancetgh Published online December 6, 2023 https://doi.org/10.1016/S2214-109X(23)00454-0
11
Series
JPV developed the outline and coordinated the design, input, and writing
of this third paper in the Series. The searches, screening, data extraction,
and quality assessments were performed by JPV, JJ, TLa, GS, and DK, with
support from EA, VD, and VF. All authors participated in the development
and design of this study, and contributed to the interpretation of findings
and writing of all sections. All authors agreed to submit the manuscript.
15
Declaration of interests
We declare no competing interests.
17
Acknowledgments
This paper reflects the views of the named authors, and not the views of
their organisations, or the views of UNDP-UNFPA-UNICEF-WHOWorld Bank Special Programme of Research, Development, and
Research Training in Human Reproduction or WHO. JPV is supported
by a National Health and Medical Research Council (NHMRC)
Investigator Grant (GNT1194248) and CSEH is supported by an NHMRC
Fellowship (APP1137745). The time contribution of JJ, GS, and DK was
in part supported by funds from the United States Agency for
International Development and the UNDP-UNFPA-UNICEF-WHOWorld Bank Special Programme of Research, Development and
Research Training in Human Reproduction, a co-sponsored programme
executed by WHO. No specific funding support was provided to any
other authors. We thank Jen Ramson and Anna Shalit for support on
screening, data extraction, and quality assessment tasks, and
Shan Huang in the preparation of the figures.
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www.thelancet.com/lancetgh Published online December 6, 2023 https://doi.org/10.1016/S2214-109X(23)00454-0